Name: Luo Xianglian                                                                  Sex: Female

Age: 49                                                                                      Marital Status: Married

Nationality: China                                                                      Date of Admission: Feb. 27, 2013

Companion: Alone 

                                  First Medical Record 

Date: Feb. 27, 2013                                Time: 12:00 a.m. 

This 49-year-old woman had been suffering from the neck bending backwards, pains over her neck and shoulders, accompained with numbness over her lower limbs for 7 years, and expectoration for one months. She was hospitalized in our hospital as a patient with spasmodic torticollis for TCM treatment at 12:00 a.m. on Feb. 27, 2013. 

Essential for Diagnosis: 

1. Medical History: There were the head bending backwards, pains over her neck and shoulders, and accompanied with numbness over her lower limbs for 7 years, expectoration for one month. In May of 2006, she fallen down from about 5 meters high tree. This accident caused the injury. And in September, there was neck injury, a man injured her neck with an umbrella. There were no food and medicine for her to get allergy response.

2. When the patient came to our hospital, her head was bending backwards. There were pains over his neck and shoulders. If she lift her arms and throw back her shoulder, she felt comfort. There was numbness over her left arm with limitation of movement. There were pains over her lower limbs and her joints. She could not stand for a long time. She even could not walk by herself. Her condition became worse when her emotion was tense. The pains deteriorated when the weather was getting hot, while the pains relieved if the temperature was below 20℃. She felt discomfort over her stomach and she had slight stomachache. She had anxious facial expression. Her sleeping was not good. She had low back pains. Her urination and bowel movement were normal.

 3. T: 36.8°C   R: 24 times/minute    P: 62 times/minute   BP: 120/80mmHg 

4. The patient had normal growth, physique and spiritual status and anxious facial expression. Her head was bending backwards involuntarily. She cooperated with doctors when the physical examinations were made. There was no yellow skin or yellow sclera over her whole body. There was no enlargement over her superficial lymph node. She had regular features. Her trachea and chest were symmetrical. The jugular vein was of no engorgement. There was no enlargement over her thyroid. Sound of breathing in the lungs was clear, without any rhonchi. Rhythm of his heart was 62 times per minute. Heart rate was irregular with no murmurs. Her abdomen was soft with no pressing pains and enclosed masses. There were obvious pressing pains around her shoulder-joints. There were no pains and edema over her lower limbs. The tongue body was dark red with yellow coating. The pulse was taut and wiry.

5. CT examination and magnetic resonance imaging at the No. 1 People’s Hospital in Huaihua, 535 Army Hospital and Huaihua TCM Hospital, the result all showed that she had cervical vertebra degenerative change. There was bulge over her 5^th and 6^th cervical vertebrae.

Diagnostic Differentiation: 

TCM: 1. Spasm Impediment

2. Stomachache

Western Medicine diagnosis: 1. Spasmodic Torticollis

2. Gastric Ulcer

Treatment strategy and nursing: 

1. Routine care of traditional Chinese internal medicine. 

2. Grade Ⅱ care, companion, common diet.  

3. Complete the related examination, three routine inspection, the function of the kidneys and the liver, 6 modes of HBV, anti-O, ESR, RF and C-Spine PALAT.  .

4. Herbal tea: one dosage a day and drink twice 

5. Acupuncture and massage: once a day 

6. Avoid wind-cold, regular daily life, have a good mood and take care of diet.

Date: Feb. 28, 2013                                      Time: 9:30 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. This 49-year-old woman had been suffering from the neck bending backwards, pains over her neck and shoulders, accompanied with numbness over her lower limbs for 7 years, and expectoration for one month. She could not stand for a long time. She even could not walk by herself. Her condition became worse when her emotion was tense. The pains deteriorated when the weather was getting hot, while the pains relieved if the temperature was below 20℃. She felt discomfort over her stomach and she had slight stomachache. She had anxious facial expression. Her sleeping was not good. She had low back pains. Her urination and bowel movement were normal. The tongue body was dark red with yellow coating. The pulse was taut and wiry. The doctor made the proper treatment strategy.

Date: March 01, 2013                                      Time: 9:30 a.m.

The patient said she felt the head and neck bending backwards slightly relieved. Her condition was stable. To continue the same formula.

Date: March 03, 2013                                      Time: 9:30 a.m.

The patient said the head and neck bending backwards relieved a little. Her sleeping was better. Especially after using the Chinese medicine for soaking the feet, she felt her neck was powerful. She can bend her neck forwards. And she felt comfort. The vital signs of the patient were stable. The tongue body was dark red with yellowish coating. Her pulse was thin and wiry. 

Date: March 05, 2013                                      Time: 9:30 a.m.

The vital signs of the patient were stable. Yet the patient said her head bending backwards became worse. And there were pressing pains over her neck and shoulders. The doctor adjusted the formula.

Date: March 07, 2013                                      Time: 9:00 a.m.

The patient said her symptoms relieved in recent days. The pains disappeared completely over her legs. She could move flexibly. She still had the pressing pains over her shoulders.

The patient said her condition was stable. She said it was much more powerful when she lifted her arms. Yet her head and neck still bended backwards involuntarily. The other symptoms relieved. The doctor adjust the formula again.

Date: March 13, 2013                                      Time: 9:30 a.m.

The patient said the head and neck bending backwards was better. It was comfortable when she moved her neck. Her appetite and sleeping were good. Her tongue body was slightly red with thin and yellow coating. Her pulse was powerful, taut and wiry.

Date: March 16, 2013                                      Time: 10:30 a.m.

The patient said her condition obviously improved after taking the herbal tea, the acupuncture and massage. It was much more power when she lifted her arms. And her head and neck bending backwards improved greatly. The pains over her lower limbs disappeared completely. And she could walk powerfully. She could move her legs flexibly. Her spirit was better. And her insomnia was cured. The pressing pains over her neck and shoulders relieved. The patient decided to leave our hospital tomorrow. And taking the herbal tea back to continue the treatment.

Doctor’s advice after leaving hospital: 

1. Avoid wind-cold. 

2. Take care of the diet.